﻿
<div class='inputContainer'>
    <div class='input'><label for='tbInsuranceName'>InsuranceName:</label><input type='text' id='tbInsuranceName' name ="tbInsuranceName"/></div>
    <br />
    <div class='input'><label for='tbAddress1'>Address1:</label><input type='text' id='tbAddress1'/></div>
    <div class='input'><label for='tbAddress2'>Address2:</label><input type='text' id='tbAddress2'/></div>
    <div class='input'><label for='tbCity'>City:</label><input type='text' id='tbCity'/></div>
    <div class='input'><label for='tbState'>State:</label><input type='text' id='tbState'/></div>
    <div class='input'><label for='tbZIP'>ZIP:</label><input type='text' id='tbZIP'/></div>
    <div class='input'><label for='tbMainPhone'>MainPhone:</label><input type='text' id='tbMainPhone'/></div>
    <div class='input'><label for='tbFax'>Fax:</label><input type='text' id='tbFax'/></div>
    <hr />
    <div class='input'><label for='tbNotes'>Notes:</label><input type='text' id='tbNotes'/></div>
    <div class='input'><label for='tbPolicyNumber'>PolicyNumber:</label><input type='text' id='tbPolicyNumber'/></div>
    <div class='input'><label for='tbGroupNumber'>GroupNumber:</label><input type='text' id='tbGroupNumber'/></div>
    <div class='input'><label for='tbNetworkNumber'>NetworkNumber:</label><input type='text' id='tbNetworkNumber'/></div>
    <div class='input'><label for='tbCoverageDate'>CoverageDate:</label><input type='text' id='tbCoverageDate'/></div>
</div>

